Laryngeal sensory deficits in patients with chronic cough and paradoxical vocal fold movement disorder.

OBJECTIVES/HYPOTHESIS: Although the diagnostic accuracy of paradoxical vocal fold movement disorder and chronic cough has improved, the underlying pathophysiology remains relatively unknown. We hypothesize that one potential etiological factor in these patients is an aberrant laryngeal sensory response and sought to determine if respiratory retraining in addition to antireflux therapy alters this aberrant response. STUDY DESIGN: Retrospective, outcomes. METHODS: Sixteen patients who had been on at least 3 months of twice-daily proton pump inhibitors with no subjective improvement in their primary complaint of cough, self-reported symptoms of gastroesophageal and laryngopharyngeal reflux, and concurrent paradoxical vocal fold movement (PVFM) were included in the current study. In addition to continuing twice daily pharmacological therapy, subjects underwent a course of respiratory retraining. Outcome measures including the Reflux Symptom Index (RSI), transnasal flexible laryngoscopy, and laryngopharyngeal sensory discrimination thresholds were obtained prior to and following a course of respiratory retraining. RESULTS: Mean bilateral laryngeal sensory response improved significantly after combined respiratory retraining and aggressive proton pump inhibitor therapy (P = .01). In addition, mean RSI score decreased significantly following treatment (P = .02). Specifically, 13 of 16 patients experienced improved sensory response, corresponding with patient reports of improved PVFM symptoms following treatment. CONCLUSIONS: Aberrant laryngeal sensation was identified in patients with PVFM and chronic cough. This response, however, normalized following a limited course of respiratory retraining, corresponding with improved patient symptoms.

A prospective, randomized trial of nerve monitoring of the external branch of the superior laryngeal nerve during thyroidectomy under local/regional anesthesia and IV sedation.

BACKGROUND: The aim of this study was to assess the impact of the neuromonitoring of the external branch of the superior laryngeal nerve (EBSLN) on the voice quality after mini-incision thyroidectomy under local/regional anesthesia and intravenous sedation. METHODS: Patients undergoing mini-incision thyroidectomy under local anesthesia were prospectively randomized for either nerve monitoring of the EBSLN (group 1) or no nerve monitoring (group 2). Voice and swallowing assessment were obtained by using the Voice Handicap Index-10 (VHI-10) and the Reflux Symptom Index questionnaires (RSI) before surgery and at 3 weeks and 3 months after surgery. RESULTS: Recruitment led to 22 patients in group 1 and 25 patients in group 2. The rate of visualized EBSLN was higher in group 1 (66% vs 21%; P = .003). Contrary to group 1, in group 2, the median total VHI-10 score was significantly higher 3 months after surgery (P = .034) compared with preoperatively, indicating a subjective voice handicap. In both groups, there was no difference in median total RSI score before surgery or at 3 weeks and 3 months after surgery. CONCLUSION: Nerve monitoring aids in the visualization of the EBSLN during mini-incision thyroidectomy under local/regional anesthesia and leads to an improvement in patient-assessed voice quality after surgery but does not impact swallowing.

Respiratory retraining therapy and management of laryngopharyngeal reflux in the treatment of patients with cough and paradoxical vocal fold movement disorder.

OBJECTIVES: We describe the outcome of patients with cough and paradoxical vocal fold movement disorder (PVFMD) treated with respiratory retraining therapy and management of laryngopharyngeal reflux (LPR). METHODS: Twenty patients with the complaint of cough were given a diagnosis of PVFMD and treated with proton pump inhibitors for a minimum of 6 months followed by 3 to 5 sessions of respiratory retraining therapy. Pulmonary function testing (PFT) and subjective rating of cough and reflux (reflux symptom index; RSI) were performed. Also, PFT and rating of cough were performed on a group of 10 healthy volunteers with no complaint of cough. RESULTS: The study group comprised 13 women and 7 men. The baseline cough rating and ratio of forced inspiratory volume at 0.5 second to forced inspiratory vital capacity (FIV0.5/FIVC) on PFT were significantly worse in the treatment group than in the control group. After therapy, 20 patients (100%) experienced improvement in cough, 19 patients (95%) experienced improvement on PFT, and 17 patients (85%) experienced improvement in the RSI score. The differences were statistically significant. CONCLUSIONS: Respiratory retraining therapy combined with management of LPR is an effective treatment for patients with cough and PVFMD when a single-modality treatment is not sufficient.

Respiratory retraining of refractory cough and laryngopharyngeal reflux in patients with paradoxical vocal fold movement disorder.

OBJECTIVES/HYPOTHESIS: The objective was to describe a case series of patients with refractory cough and paradoxical vocal fold movement disorder treated with respiratory retraining therapy. STUDY DESIGN: Retrospective review of a case series in a tertiary medical care center. METHODS: Five patients with laryngopharyngeal reflux were identified with refractory cough and paradoxical fold movement disorder on transnasal fiberoptic laryngoscopy by a greater than 50% reduction in airway during inspiration. The were four women and one man (age range, 42-67 y). All patients had normal forced vital capacity and forced expiratory flow but decreased ratio of forced inspiratory volume at 0.5 seconds (FIV(0.5)) to forced inspiratory vital capacity (FIVC) before starting therapy. All patients were treated with more than 6 months of twice-daily proton pump inhibitor therapy with improvement in reflux symptoms but persistent and severe daytime cough. They were subsequently treated with respiratory retraining therapy. Patients were asked to rate subjectively the severity of cough at the onset and conclusion of therapy. All patients underwent pulmonary function testing before and after therapy. Long-term follow-up ranged from 5 to 17 months. RESULTS: Patients received two to seven sessions of respiratory retraining therapy. The mean severity score changed from 9.2 before therapy to 1.3 after therapy. All patients subjectively described an improvement in the severity of their cough. Transnasal flexible laryngoscopy demonstrated improvement in paradoxical vocal fold movement, and pulmonary function testing showed improvement in the FIV(0.5)/FIVC ratio. CONCLUSION: Patients with laryngopharyngeal reflux and refractory cough in the absence of pulmonary disease should be evaluated for paradoxical vocal fold movement disorder. Respiratory retraining therapy may represent an effective therapy for cough in the absence of relief from standard management of laryngopharyngeal reflux.